Yesterday was not an unusual day for me in many respects, but comments on LinkedIn by a doctor that it was ‘very disturbing’ that unions in Tasmania might pursue a change that meant that PTSD was assumed as caused by work in some high risk occupations, lead me to reflect on some fundamentals about the role of doctors in our compensation systems and about the raison d’être for the schemes themselves. Not that I necessarily disagree that work causation should not be assumed without evidence, but more fundamentally what is a doctor’s role within our compensation systems and what is the objective of compensation schemes.

I have previously provided some commentary on related issues, the CommInsure scandal –Another Elephant? – Lessons from the Comminsure Scandal

Day to Day Experiences

In addition to snippets from Social Media, my interactions with patients and other health professionals at work and at professional gatherings provide examples of some of the roles taken by doctors in compensation systems.

I saw a patient to provide a report to their lawyer, mainly about the extent of impairment. The patient is well-known to the practice and has progressive CRPS as a complication of a work-related limb injury. The condition had progressed to affect the contralateral limb. The claim is approaching settlement. I am providing an opinion about impairment. The insurer have sought opinions from another doctor who, at the last assessment, tried to justify the use of an impairment methodology that lead to the lowest impairment rating, barely accepting that there was a significant medical disorder, let alone a progressive debilitating disorder preventing any return to work or quality of life. Since my previous assessment about a year earlier, the condition has progressed with X-ray evidence of osteoporosis, gross swelling, skin changes and other classic features of this horrible condition, yet my expectation, if the other doctor is true to form, it will again be argued whether the condition is real or an assessment of the condition conducted in a way favourable to the insurer’s liability. I hope my predictions are proven wrong, but experience tells me otherwise. Is this the role of a doctor in our compensation system?

I saw another young patient under my care who has suffered musculoskeletal injury at work. The patient had become suicidally depressed with a near-successful suicide attempt as a result of the incapacity and effects on their career prospects. There is no previous psychological history. I am reluctant to add the psychological diagnosis to the certificate because I know it will lead to a dispute and complicate management. A proposal for limited ‘without prejudice’ funding to assist with psychological treatment (already psychological treatment is mainly funded by the public purse) has already been rejected. What is my role as the doctor coordinating treatment here? I suspect a no-win situation for the patient whatever I do about trying to expedite appropriate holistic management addressing physical and psychological factors, but will do my best.

Another patient, also well-known to me, contacted me yesterday concerned about a letter from the insurer advising about a dispute based on an IME assessment. Despite a legal requirement that the insurer provide the treating doctor with the IME report, I hadn’t received a copy yet to be able to talk through the opinion with the patient. More unnecessary stress for the patient. I will talk that through with them.

I did have some more satisfying experiences yesterday. A worker with back pain referred by their employer attended for advice about management. The employer isn’t concerned about the cause, they just want to get their employee better. I was able to help. I also reviewed another patient where a clear occupational disease diagnosis had been established, based on objective investigations. There are clear workplace implications – a change of job role is necessary. So far this has been accepted by the worker and hasn’t been challenged by his employer (indeed they seemed pleased to have an answer about the cause) and I remain hopeful that the insurer will accept the situation and not try some strategy to escape their role is supporting appropriate management. This is the role of a doctor working within a compensation system.

Another recent experience is my attendance at a conference about the health effects of compensation systems. I have just come back from the Australasian Compensation Health Research Forum conference – ACHRF 2016  in Melbourne. The conference was co-sponsored by the leading Melbourne-based research organisation in this field in Australia – The Institute for Safety, Compensation and Recovery Research (ISCRR) and the New Zealand Accident Compensation Corporation (ACC). I commend the conference organisers and the many insurer and compensation authority, researcher and health professional delegates who attended to learn about the state of knowledge in this relatively new area of research. I was disappointed that I couldn’t see anyone amongst the nearly 200 delegates from Tasmania’s Private Insurers or WorkCover/WorkSafe Tasmania. They didn’t get to see the presentation I made on behalf of AMA Tasmania about a unique initiative, driven by concerned doctors putting forward ideas to improve health outcomes in Tasmania’s Workers Compensation System. Most initiatives are driven by insurers trying to improve scheme outcomes or researchers and academics. The AMA proposal involves an alternative clinical pathway for workers assessed early on in their claims by GP’s as having a potential poor prognosis. See the earlier article for details – Towards Simplicity – Complex Case Management by Doctors. The AMA ideas did achieve some recognition though, with the conference organising committee’s award for the best Poster Presentation at the conference. Is involvement in system level change an appropriate role for doctors? I think so – otherwise I declare I am a hypocrite.

Dr Jason Thompson (@Simulated_Jase),  a well-known researcher at ISCRR tweeted today about the release of a study – Differences in perceived fairness and health outcomes in two injury compensation systems: a comparative study. This study provides evidence that differing ‘perceptions of fairness’ between compensation systems can affect outcomes. I doubt this study will immediately or directly affect what I do in my day-to-day medical practice, but it is an example of the growing evidence base about the factors that can affect outcomes for claimants in compensation systems, relevant to the design of compensation systems.

Over the last few days there has been publicity about PTSD in Ambulance Officers and Firefighters with a recent Four Corners Programme Insult to Injury. Concern about this issue has now extended to the south of the country with Tasmanian Ambulance Officers and Firefighters asking for system change to avoid the damaging effects of having to prove PTSD as highlighted earlier in this article.

The Conversation published an article by Petra Skeffington 2 days ago about PTSD – One in five police officers are at risk of PTSD – here’s how we need to respond. The following notable statement appears in this article:

“However, an ethical compensation system must deliver timely and warranted assessment and outcomes for claims in a way that protects those who are distressed and psychologically unwell.”

My opening paragraph also refers to this issue and the concern about a doctor seemingly having the principal motive of raising concern about a measure designed to improve health, without any apparent examination of the evidence from a health perspective. One could be forgiven for concluding that the motive was to protect the financial viability of the insurer rather than advancing health.

In another blog article I referred to Dr Barry Gilbert’s view of the role of an IME assessor – Barry Gilbert on IME’s.

It is worthwhile revisiting one of his most important points:

“it is essential doctors always use their skills and authority to always act in the patient’s best interests”

I agree with that sentiment.

Why Do We Have Compensation Systems?

Workers Compensation Schemes are intended to serve the interests of those injured at work and are not primarily concerned with providing a profitable line of business for a financial organisation. Of course there is a need for the system to be affordable to the payers, the businesses and organisations that pay premiums and ultimately the community. It is worthwhile however remembering that while most workers don’t have choice about whether they end up within a compensation system, private insurers do have a choice about whether to participate in the offer of insurance along with the expertise in risk management to calculate a fair premium for that role.

Insurers have a choice to participate in compensation systems – workers don’t!

Doctors should be professionals whose overriding responsibility is to advocate for optimum health outcomes, no matter their role or who pays them. This is so whether doctors are working at individual case level or providing strategic or policy advice at a system level.

Doctors can provide advice to whoever seeks it, but it is not their role to bend the medical truth for the financial benefit of organisations that choose to operate in the compensation space. It is their role to be fully informed about health issues, including the impact of the various processes involved in assessment on the individuals involved. Indiscriminate surveillance is a good example of a potentially harmful practice, as raised by the recent Four Corners Programme.

See my earlier blog article for my own perspective on this issue:

Surveillance – Sharp Focus or Blunt Instrument?

Doctors should also be concerned about processes that lead unfairly to avoidance of liability by any third-party payer. This is not only because that might disadvantage the individual’s access to treatment and rehabilitation, but because cost-shifting of health care costs from  insurers and employers to the public purse has the potential to overload our already overstretched Public Health System and remove the incentive for employers to address controllable health risks.

In conclusion, Doctors who work within compensation systems need to be cognizant of the growing evidence about the health effects of compensation systems and to always act in the interests of health outcomes whatever their role.